Provider Demographics
NPI:1578384905
Name:JORDAN, NIA M
Entity type:Individual
Prefix:MS
First Name:NIA
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NIA
Other - Middle Name:M
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2121 W 157TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4736
Mailing Address - Country:US
Mailing Address - Phone:310-678-8170
Mailing Address - Fax:
Practice Address - Street 1:396 S CALIFORNIA AVE UNIT 2213
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91793-3488
Practice Address - Country:US
Practice Address - Phone:213-634-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist